Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thyroid nodules

John Chaplin

www.thyroid.co.nz

Nick McIvor

www.neck.co.nz

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thyroid Nodules

• Common

– 3-5% palpable

– 50-70% ultrasound

– Increase with age

– More in women

– 90-95% benign

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thyroid Nodule

• What do you want to know?

– Is it malignant?

– Is it toxic?

– Is it compressive?

– Cosmetic effect?

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it malignant?

Around 5-10% malignant

– Decision algorithm for resection based on combination of:

• Clinical

– History

– examination

• Cytology

• Bloods

• Radiology

– Ultrasound

– CT/ MRI

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it malignant?-History

• Risk Factors– Family history

• Papillary– RET-PTC gene mutation

– x2 first degree relatives

• Medullary

– Familial MTC

– MEN 2a, 2b

» RET oncogene mutations

– Radiation exposure

• Therapeutic

• Environmental

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Examination

– Nodule 90%

– Can be nodule in MNG

– Nodes 10%

– Extrathyroid 3-5%

• Hoarseness

• Airway

• Dysphagia

• Skin

– Distant 3-5%

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Ultrasound

• Report says suggestive of PTC – Solid vs cystic

– Isolated vs multiple

– Margins -well defined or indistinct

– Halo - regular or irregular

– Shape size density

– Calcification

• 3 patterns

– Microcalcification ( highly susp)

– Eggshell calcification

– Macrocalcification

– Blood flow

• 3 patterns

– Peripheral

– Scant internal

– Prominent internal (Highly susp.)

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Malignant nodule

• Large >4cm

• Solitary

• Taller than wide shape

• Solid Hypoechoic

• Absent or irregular halo

• Infiltrative margin

• Microcalcification

• Intranodular blood flow

• Associated nodes with

similar features

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it malignant ?-FNA

• Possible results:

Bethesda category %malig

I. Non diagnostic 3-8%

II. Benign 0-3%

III. Atypical follicular n.sp. 8-15%

IV. Follicular neoplasm 20-30%

V. Suspicious for cancer 50-60%

VI. Carcinoma 97-100%

FNA is a safe test with negligible risk of seeding

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

FNA results

Bethesda Plan

I. Repeat FNA (USG)

II. Discuss with patient

III. Repeat FNA or lobectomy

IV. Diagnostic lobectomy

V. Lobectomy frozen section

VI. Total thyroidectomy(+/-nodes)

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it toxic/hypothyoid? History/exam

• Toxic• Heat intolerance• Irritability • Tremor• Exopthalmos• Lid lag• Goitre/ nodule

• Hypothyroid• Fatigue • Sluggish reflexes• Oedema• Alopecia• Dry skin

• May be subclinical

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it toxic/hypothyroid?Bloods

• Thyrotoxic

– TSH= supressed

– T4, T3= elevated

– Thyrd Abs +ve in 50%

Graves

– Thy Stim Ig =+ve in Graves

• Hypothyroid

– TSH= elevated

– T3,T4= low

– Thyroid Abs = +ve 90%

TSH most senstive. ie. can have altered TSH without T3, T4

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

TSH supressed & TSI –ve

(partic with nodule or goitre)Scintiscan

• Toxic Goitre

• Toxic Nodule(s)

Toxic nodules are almost never malignant

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thyrotoxicosissurgery vs radio-iodine

• Surgery– Advantages

• Single treatment

• Minimal risk hypothyroidism in ipsilateral nodule

• Reduced dysthyroid eye disease in Graves

• Better for toxic goitre

– Disadvantages• Scar

• complications

• RAI– Advantages

• No surgery

• May be better in small Graves without eye disease

– Disadvantages

• Need repeat doses in large thyroid

• Risk of hypothyroid in toxic nodule

• Does not remove antigen

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it compressive?

• Symptoms

– Pressure

– Dysphagia

– Voice

– Cough

– Short of breath

– Exercise intolerance

– OSA

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Is it compressive?

• Signs

– Stridor, wheeze,

cough, SOB

– Absent lower border/

dull to percussion

thorax

– Sleep apnoea

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Compressive goitre

• Investigations

– Resp function tests

• Fixed obstruction

– Laryngeal exam

• Endoscopy

• Voice analysis

– CT

• Thoracic extension

• Airway compromise

• Recurrence

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thoracic goitre

• CT

– Shows thoracic extension

– Allow planning of access

– Rare to split sternum but need

CTSU surgeon

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Cosmesis

• Trade off:

– Nodule vs scar

– Risk op vs no op

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

Thyroid NoduleSummary

• Essential tests

– FNA

• Risk malignancy

– Ultrasound

• Risk malignancy

– TFT

• Risk toxicity

• ( or hypothyroidism)

• Secondary tests

– Voice analysis

– CT scan

– Scintiscan

– TSIg

– Thyroid antibodies

– Resp function tests

Auckland

Head & Neck

Associates

Auckland Head and Neck Associates

www.neck.co.nz

www.thyroid.co.nz